DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Gallbladder pain.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female who arrived to the emergency department ambulatory. She has a history since August last year of intermittent pain in the right upper quadrant, more postprandial in nature, some nausea, no vomiting. The patient had a gallbladder ultrasound performed, which revealed cholelithiasis. She has been referred to see Dr. John Doe for the first time next Saturday; however, the pain exacerbated and came here for evaluation. She is not on any analgesics or antiemetics at home.
PAST MEDICAL HISTORY: No chronic illnesses.
PAST SURGICAL HISTORY: None.
SOCIAL HISTORY: Positive smoker, half pack a day.
ALLERGIES: NKDA.
REVIEW OF SYSTEMS: Remainder of systems has been reviewed and is negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 38.6, heart rate 98, respiratory rate 18, blood pressure 138/72, and pulse oximetry 97% on room air.
GENERAL: Alert, in no distress.
HEENT: Head: Scalp is clear.
NECK: Supple, no JVD or masses.
HEART: No murmur.
ABDOMEN: Soft, nondistended with mild epigastric tenderness, without rebound or guarding. Positive bowel sounds. Negative Murphy’s sign.
BACK: No CVA tenderness.
EXTREMITIES: No gross edema.
SKIN: Warm and dry.
NEUROLOGICAL: Intact.
DIAGNOSTIC DATA: The official gallbladder ultrasound report from the outside hospital revealed cholelithiasis with some mild gallbladder wall thickening. No common bile duct dilatation, no other abnormalities seen. This is per the radiologist.
Lab work today included lactic acid 0.8, glucose 86, sodium 140, potassium 3.8, chloride 104, bicarbonate 26, BUN 10, creatinine 0.7, ionized calcium 1.6. Amylase 50, lipase 34, total protein 7.8, albumin 4.8, total bilirubin 0.4, alkaline phosphatase 88, ALT 42, AST 28. WBC 6.4, H and H of 14.8 and 41.2, platelet count 204,000. Serum beta hCG was negative. Abdominal films, per the radiologist, no acute obstruction seen.
EMERGENCY DEPARTMENT COURSE AND TREATMENT: The patient was administered Toradol 30 mg IV and Zofran 4 mg IV with improvement of symptomatology.
CLINICAL IMPRESSION: Acute biliary colic.
DISPOSITION: Discharged home.
DISCHARGE MEDICATIONS: Vicodin-ES 1 p.o. q.8 h. p.r.n., number 20, no refills. Zofran 4 mg 1 p.o. q.8 h. p.r.n. nausea and vomiting.
DISCHARGE INSTRUCTIONS: Return for further problems. Follow up with Dr. John Doe.
